Hospitalization acute episodes

Manic, Hypomanic, and Mixed Episodes. The first step in managing an acute episode of BPAD is to choose the appropriate venue for treatment. Even when the patient is not overtly suicidal, the agitation, disinhibition, and impulsivity inherent to a severe manic or mixed episode of the disorder commonly require hospitalization. Hypomania, however, can usually be managed outside the hospital with frequent outpatient visits. This is particularly true if the longitudinal course of the patient s illness indicates that the patient is unlikely to progress to a full-blown manic episode. 

Brief History. R.F., a 63-year-old woman, has been receiving treatment for schizophrenia intermittently for many years. She was last hospitalized for an acute episode 7 months ago and has since been on a maintenance dosage of haloperi-dol (Haldol), 25 mg/d. She is also being seen as an outpatient for treatment of rheumatoid arthritis in both hands. Her current treatment consists of gentle heat and active range-of-motion exercises, three times each week. She is being considered for possible metacarpophalangeal joint replacement. 

Bipolar illness appears to be a changing illness. A comparison of psychiatric services in North-West Wales in the 1890s and the 1990s has shown that the rate of admissions increased from 4.0 every 10 years to 6.3 every 10 years (11). Similarly, the daily hospital occupancy rate for patients with bipolar affective disorder rose from 16 per million to 24 per million. While acknowledging that there have been many social changes that may have contributed to these differences, the authors suggested that current treatments leave much to be desired. Reviews of lithium treatment have reached similar conclusions, particularly regarding the effect of lithium in acute episodes (12). 

Access to healthcare services is a marker of primary care quality, because acute episodes of asthma are avoidable if they are managed and appropriately treated in the community. Gaps in access to medical services between urban and rural areas exist, and include such things as convenience of transportation, range of services provided locally, as well as the cost for medical treatment. The previous literature indicates that a lack of medical services and specialists are more common in rural than in urban areas (Rural Healthy People 2010), and there is a low utilization efficiency of hospice services in rural areas (Gessert et al. 2006) in addition, disparities exist in the threshold for admission to hospital or clinic care, between urban and rural physicians (Russo et al. 1999). 

The studies do, however, suggest that primary end points of number of acute exacerbations and hospital admissions may be a more sensitive measure than mortality. Tuggey et al. (147) examined the economic impact of home NIV in COPD patients with recurrent exacerbations who responded well to NIV during these acute episodes. Good tolerance to home NIV resulted in a cost saving of 11,720 euros (5698-17,743 euros) per patient per year. The number of hospital admissions in the year on NIV compared to the previous year was reduced from five to three and hospital days decreased from a mean (SD) of 78 (51) to... 

Intrinsic asthma, also called idiopathic asthma, usually develops in adulthood. In intrinsic asthma allergic factors are not demonstrable. Episodes of intrinsic asthma may be triggered by a variety of stimuli, eg, emotional state, exposure to cold air, or inert dusts. Both intrinsic and extrinsic asthmatics can be prone to exercise-induced attacks. Individuals who experience a combination of extrinsic and intrinsic asthmatic reactions have mixed asthma. Status asthmaticus refers to an especially acute life-threatening asthma attack which is resistant to normal treatments and which may require hospitalization in order to stabilize the patient. 

Unless ordered otherwise, the nurse should save all stools that are passed after the drug is given. It is important to visually inspect each stool for passage of the helminth. If stool specimens are to be saved for laboratory examination, the nurse follows hospital procedure for saving the stool and transporting it to the laboratory. If the patient is acutely ill or has a massive infection, it is important to monitor vital signs every 4 hours and measure and record fluid intake and output. The nurse observes the patient for adverse drug reactions, as well as severe episodes of diarrhea. It is important to notify the primary health care provider if these occur. 

The risk of relapse in discontinuation trials depends on many non-pharmacological, often poorly controllable factors, notably the expectations of the patients, doctors and nurses, other environmental factors, the duration of hospitalization and prior treatment, and the time interval since the last acute psychotic episode. On the basis of an analysis of 14 discontinuation trials, Kane and Lieberman (1987) found that the relapse rate varied greatly from study to study depending on the trial, relapse rates of 30 86% with clustering around 60 70% have been reported in the first 12 months after placebo substitution. According to Kane and Lieberman, this scatter is a result of the different inclusion criteria applied and the different definitions of relapse . 

One aspect of great importance in the long term, namely a reduction in the relapse risk after the remission of an acute schizophrenic episode, forms the subject of two comprehensive studies involving schizophrenic patients who had been discharged from hospital (Hogartv and Goldberg, 1973 May et al, 1976) see Boxes 8.2 and 8.3. 

After several recurrences, substantial evidence indicates that maintenance treatment is necessary. Patients who have had many episodes but make a good recovery from the acute exacerbation benefit most from maintenance medication. Those who have the least drug-psychotherapy versus no treatment difference tend to benefit least from maintenance pharmacotherapy (219). For example, Prien and his colleagues (212, 220, 221) found that chronically hospitalized patients maintained on low-dose antipsychotics had fewer relapses than those who needed more medication (relapse percentages by categories of medication dose and chronicity Table 5-19). 

At age 12, the patient was admitted with acute chest pain from a left spontaneous pneumothorax (air within the pleural cavity).This required hospitalization and chest tube insertion, but he recovered without sequelae. After the resolution of this problem, pulmonary function testing revealed findings of both severe airway obstruction and destruction of alveolar lung tissue, consistent with emphysema. No further pulmonary problems occurred until the patient was age 16 years, when he developed occasional episodes of bronchospasm (spasmodic contraction of the smooth muscles of the bronchus). Pulmonary function studies at that time, though improved from those immediately following his pneumothorax, still revealed combined obstructive and destructive lung disease. 

Although mania has been associated with olanzapine (SEDA-24, 68 SEDA-25, 68 SEDA-26, 62), it has also been used in the treatment of acute mania. In a 12-week, double-blind, double-dummy, randomized trial, 120 patients with bipolar disorder type I hospitalized for an acute manic episode were randomly assigned to either sodium valproate (n = 63) or olanzapine (n = 57) and were followed in hospital for up to 21 days (60). Valproate and olanzapine had similar short-term effects on clinical or health-related quality of life outcomes in bipolar disorder adverse effects that occurred in a higher percentage of olanzapine-treated than valproate-treated patients included somnolence (47% versus 29%), weight gain (25% versus 10%), rhinitis (14% versus 3%), edema (14% versus 0%), and slurred speech (7% versus 0%) no adverse events occurred significantly more often with valproate. 

A 58-year-old man is hospitalized in cardiac intensive care following an acute myocardial infarction. He has had recurrent episodes of ventricular tachycardia that have not responded to lidocaine, and an intravenous infusion of procainamide will now be administered. The patient weighs 80 kg and expected values for his procainamide distribution volume and elimination half-life are 2.0 L/kg and 3 hours, respectively. 

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